Navigating the landscape of healthcare for seniors can be complex, especially when considering long-term care and financial assistance. For residents of Massachusetts aged 65 and over, the Senior Care Options (SCO) program offers a valuable solution. This guide provides an in-depth look at the SCO program, outlining its benefits, eligibility criteria, and application process to help you determine if it’s the right choice for you or your loved ones.
What is the Senior Care Options Program?
The Massachusetts Senior Care Options (SCO) program is a state-sponsored healthcare initiative designed to coordinate care for seniors aged 65 and older. It’s a voluntary managed care program that integrates both Medicaid (MassHealth in Massachusetts) and Medicare benefits, although Medicare enrollment is not mandatory to participate. Primarily intended for individuals who are dually eligible for both Medicaid and Medicare, SCO is available to eligible seniors in Massachusetts, excluding those residing in Dukes and Nantucket Counties.
Through SCO, participants gain access to a comprehensive range of health services, including medical care (such as doctor visits, preventive services, and lab work), behavioral health support, and prescription medications. Crucially, SCO also covers nursing home care and a variety of Long-Term Services and Supports (LTSS). These LTSS are designed to enable seniors to maintain their independence and continue living in their homes, with family, in assisted living facilities, or adult foster care homes. Examples of LTSS benefits include adult day care, personal care assistance, emergency response systems, respite care for caregivers, and homemaker services.
Participants in the SCO program receive all their benefits through a single Medicaid plan, administered by a Managed Care Organization (MCO), specifically referred to as a Senior Care Organization within the SCO framework. These organizations are essentially private healthcare companies that operate networks of healthcare providers. Each SCO participant selects a primary care provider (PCP) within their chosen senior care organization. This PCP collaborates with a team of network providers, including specialists, registered nurses, and geriatric support service coordinators, to develop a personalized care plan tailored to the individual needs of each program member.
Massachusetts offers a selection of senior care organizations for individuals to choose from. The available options can vary depending on the participant’s location within the state, as not all organizations serve every area. It’s important to note that the SCO program is not available in Dukes and Nantucket counties.
Unlike some other long-term care Medicaid programs, SCO does not offer a participant-directed care option, meaning beneficiaries cannot hire caregivers of their choice under this program.
The Senior Care Options Program operates as an entitlement program. This means that anyone who meets the eligibility requirements is guaranteed to receive program benefits immediately. There are no enrollment caps or waiting lists for participation in SCO.
Established in 2004, Senior Care Options is part of the 1115(a) Medicaid Demonstration program. In Massachusetts, Medicaid is known as MassHealth, with MassHealth Standard specifically catering to individuals aged 65 and over.
It’s important to understand the concept of Medicaid Managed Care. Medicaid typically pays healthcare providers in two ways: “Fee-For-Service” and “Managed Care.” Under Fee-For-Service, providers are paid directly by Medicaid for each service rendered, and beneficiaries can seek care from any Medicaid-certified provider. In contrast, Managed Care involves Medicaid contracting with an MCO. Medicaid pays the MCO a fixed amount per beneficiary, regardless of the services used. The MCO then manages a network of providers who are paid by the MCO. SCO operates under this Managed Care model, requiring participants to utilize providers within the network of their chosen Senior Care Organization.
Key Advantages of the Senior Care Options Program
Enrolling in the SCO program offers numerous benefits to participants, streamlining their healthcare and support services. Participants can access all their Medicare (Part A, Part B, and Part D) and Medicaid benefits through the program. While specific benefits may vary slightly depending on the chosen senior care organization, the individualized care plan ensures that participants receive the necessary services, including long-term care services and supports (LTSS) or Home and Community Based Services (HCBS). Here’s a comprehensive list of potential benefits:
- 24/7 Nurse Phone Line: Access to round-the-clock health advice and information.
- Adult Day Care: Including specialized programs for dementia care.
- Acupuncture: Alternative therapy options.
- Behavioral Health Services: Mental health and substance abuse support.
- Care Coordination: Assistance in managing and organizing healthcare services.
- Companionship Services: Social support and engagement.
- Dental Services: Oral health care.
- Hearing Services / Hearing Aids: Addressing hearing impairments.
- Home Health Care: Medical care in the comfort of your home.
- Homemaker / Chore Services: Assistance with household tasks.
- Hospice Care: End-of-life care and support.
- Hospitalization: Coverage for inpatient hospital stays.
- Laboratory Tests / X-Rays: Diagnostic services.
- Medical Equipment / Supplies: Necessary medical aids.
- Medications: Prescription and prescribed over-the-counter drugs.
- Mental Health Services: Psychiatric and psychological care.
- Nursing Home Care: Long-term care in a skilled nursing facility.
- Personal Care Assistance: Help with daily living activities.
- Personal Emergency Response Systems: For immediate help in emergencies.
- Preventative Care / Screenings: Wellness and early detection services.
- Physician Visits: Regular check-ups and specialist consultations.
- Podiatry Services: Foot care.
- Rehabilitative Therapy: Physical, occupational, and speech therapy.
- Respite Care: Temporary relief for primary caregivers.
- Transportation: Non-emergency medical and non-medical transportation services.
- Vision Services / Eyewear: Eye exams and glasses.
Who is Eligible for the Senior Care Options Program?
To be eligible for the Senior Care Options Program, applicants must meet specific criteria related to age, residency, and health status. The program is available to Massachusetts residents who are 65 years of age or older and eligible for MassHealth Standard, the state’s Medicaid program for seniors. While MassHealth Standard enrollment is mandatory, Medicare enrollment is not a prerequisite for SCO. Applicants must reside in a geographic area where SCO is offered, excluding Dukes and Nantucket Counties. Individuals with end-stage renal disease, those living in intermediate care facilities for the developmentally disabled, or inpatients in chronic or rehabilitation hospitals are not eligible for SCO.
For a preliminary assessment of eligibility, the American Council on Aging provides a helpful Medicaid / MassHealth Eligibility Test for seniors.
Financial Eligibility: Income, Assets, and Homeownership
Financial eligibility for SCO is determined by income and asset limits, which are aligned with MassHealth Standard guidelines.
Income: The income limit for SCO is pegged to 100% of the Federal Poverty Level (FPL), adjusted annually in January, though MassHealth Standard income limits are updated each March. For the period from March 1, 2025, to February 28, 2026, the monthly income limit for a single applicant is $1,304.17. For married couples, regardless of whether one or both spouses are applying, the combined monthly income limit is $1,762.50.
Income rules differ for applicants requiring nursing home care. While there isn’t a strict income cap, most of the applicant’s income must contribute to care costs. Importantly, the income of a non-applicant spouse is not counted, and they may be entitled to a Monthly Maintenance Needs Allowance (MMMNA) from the applicant spouse. In 2025, the maximum MMMNA is $3,948 per month.
It’s worth noting that individuals enrolled in the MassHealth Frail Elder Waiver (FEW) are also eligible for SCO. FEW participants retain their waiver services and gain access to SCO benefits. FEW has more lenient income limits and allows for a Community Spouse Resource Allowance (CSRA), which protects more of a couple’s assets for the non-applicant spouse.
Assets: In 2025, the asset limit for a single SCO applicant is $2,000. For married couples, it is slightly higher at $3,000.
Similar to income, asset rules vary for nursing home care applicants. If both spouses apply, each can have up to $2,000 in assets. If only one spouse applies, the applicant can retain up to $2,000 in assets, while the non-applicant spouse is entitled to a Community Spouse Resource Allowance (CSRA). In 2025, the CSRA allows the non-applicant spouse to keep 50% of the couple’s countable assets, up to $157,920. If 50% of assets is less than $31,584, the non-applicant spouse can keep the entire amount, up to $31,584.
Certain assets are considered exempt and are not counted towards Medicaid’s asset limits. These typically include the applicant’s primary residence, household furnishings, personal effects, and one vehicle.
Depending on the pathway to SCO enrollment, a Medicaid Look-Back Period may apply. This is a 60-month period preceding the Medicaid application, during which Medicaid scrutinizes asset transfers to ensure no assets were gifted or sold below fair market value. Such transactions can violate the Look-Back Rule, leading to a Penalty Period of Medicaid ineligibility. The Look-Back Period is primarily relevant for those needing nursing home care or accessing SCO via the Frail Elder Waiver.
To estimate potential asset spend-down requirements, you can utilize a Spend Down Calculator.
Home Ownership: The home is often a significant asset, and many worry about losing it to Medicaid. Massachusetts Medicaid provides exemptions for the primary home in these situations:
- The applicant lives in the home or intends to return, and their home equity interest is $1,097,000 or less in 2025. Home equity is the home’s value minus any mortgage. Equity interest is the applicant’s ownership share of the equity.
- The applicant’s spouse lives in the home.
- The applicant has a child under 21 residing in the home.
- The applicant has a blind or permanently disabled child of any age living at home.
Further details on home protection and Medicaid can be found here.
Medical Eligibility: Functional Needs
While the Senior Care Options program serves seniors with varying levels of functional ability, those requiring long-term care must demonstrate a functional need for such services. Generally, this means needing assistance with at least one Activity of Daily Living (ADL). ADLs include essential self-care tasks like transferring, dressing, bathing, mobility, eating, and toileting. Cognitive function, including memory and decision-making, is also considered, particularly for individuals with Alzheimer’s disease or dementia.
For nursing home care specifically, a higher level of need, known as a Nursing Facility Level of Care (NFLOC), is required. This involves a more significant level of assistance with ADLs and cognitive impairments. For individuals entering SCO through the Frail Elder Waiver, a NFLOC is also necessary.
A functional needs assessment will be conducted to evaluate whether an applicant meets the functional requirements for long-term care. A dementia diagnosis alone does not automatically guarantee functional eligibility.
More information on long-term care Medicaid eligibility in Massachusetts is available here.
Strategies for Qualifying When Over Income or Asset Limits
Exceeding Medicaid’s income and/or asset limits doesn’t automatically disqualify an applicant from MassHealth or the Senior Care Options Program. Several Medicaid planning strategies can help individuals become eligible. Some strategies are relatively straightforward, while others are more complex and require professional guidance.
While MassHealth has a Spenddown Program (a 6-month deductible allowing applicants to spend excess income on medical expenses to meet income limits), this option is not available for qualifying for SCO.
For those over asset limits, options include Irrevocable Funeral Trusts, which are pre-paid funeral and burial trusts that are not counted as assets by Medicaid. Medicaid-Compliant Annuities are another strategy, converting countable assets into an income stream. Numerous other Medicaid planning techniques exist to address asset overages.
Improper Medicaid planning can lead to application denial or delays. Consulting with professional Medicaid Planners is highly recommended. These experts are knowledgeable about Massachusetts Medicaid planning strategies to achieve financial eligibility without jeopardizing benefits. Some advanced strategies, like Medicaid Asset Protection Trusts, are subject to Medicaid’s 60-month Look-Back Rule and require long-term planning. However, workarounds like the “Half a Loaf” strategy are available, and Medicaid Planners can provide guidance. To find a Certified Medicaid Planner, you can use this form.
Applying for the MassHealth Senior Care Options Program
Steps to Take Before Applying
Before starting the application process for the Senior Care Options Program, ensure you meet the basic eligibility requirements. Applying while exceeding income or asset limits without proper planning will likely result in denial. The American Council on Aging’s Medicaid Eligibility Test can help determine potential eligibility.
Gathering necessary documentation is a crucial step in the application process. This includes copies of Social Security cards, Medicare cards, life insurance policies, property deeds, pre-need burial contracts, recent bank statements, and proof of income. Missing or delayed documentation is a common cause of application delays.
The Application Process Explained
To apply for SCO, you must first apply for MassHealth (Massachusetts Medicaid). Seniors can apply for MassHealth by completing the Application for Health Coverage for Seniors and People Needing Long-Term Care Services. The completed application can be mailed, faxed, or hand-delivered to a MassHealth Enrollment Center. The application form contains the relevant fax number and address.
Individuals already enrolled in Medicaid can contact a Senior Care Organization directly for enrollment assistance. Alternatively, you can call MassHealth Senior Care Options at 1-888-885-0484 for guidance.
More detailed information about Senior Care Options is available on the official Massachusetts state website. The Massachusetts Executive Office of Health and Human Services (EOHHS) is the administering body for the Senior Care Options Program.
Understanding the Approval Process and Timeline
The MassHealth application process can take up to three months or longer from initial application to receiving an approval or denial letter. Completing the application and gathering supporting documents typically takes several weeks. Incomplete applications or missing documentation will cause further delays. While federal law mandates Medicaid offices to review applications within 45 days (90 days for disability-based applications), delays beyond this timeframe are not uncommon.
By understanding the Senior Care Options Program, its benefits, eligibility requirements, and the application process, seniors and their families can make informed decisions about accessing this valuable resource for healthcare and long-term care support in Massachusetts.
